Audit concerns noted by Senate committee

ADA reached out to Congress

July 15, 2014

By Craig Palmer

Washington–A U.S. Senate report on improving government audits of payments to health care providers cites ADA and dentist member concerns with Medicaid audits by Recovery Audit Contractors. The Affordable Care Act expanded the RAC program to Medicaid and initiated audit processes in some states in 2012.

“The American Dental Association (ADA) immediately began to hear concerns from its members and reached out to members of Congress to call for transparent, fair, consistent and statistically sound audit processes in each state,” the report said. “The ADA’s concerns primarily center around the lack of transparency in the audit process and notification procedures. Additional concerns include the statistical sampling and extrapolation methods used, the qualification of RAC auditors and the knowledge level of those auditors regarding specific state Medicaid billing regulations.”

“Audited providers were also concerned that no efforts were made by either CMS (Centers for Medicare & Medicaid Services) or the RACs to educate providers or help them learn from overpayment errors in order to avoid future audits and collections,” the report said. “The ADA’s primary concern was that the burdensome and opaque nature of the audit process may cause providers to drop out of the Medicaid program, which already struggles to attract and maintain dental professionals willing to provide critical dental services to Medicaid patients.

“In addition, the CMS is currently determining how audits might occur following implementation of the value-based modifier,” the report continued. “This modifier, as required by the ACA, will tie payment to data related to the quality of services provided. The data the CMS currently receives on quality is self-reported. This suggests a continuing need to refine audit strategies to target areas most vulnerable to improper payments.”

The Association offered recommendations to improve the audit process in testimony presented by Dr. Jessica Meeske at a July 9 roundtable convened by the Senate Special Committee on Aging and in a written statement addressed to the bipartisan committee leaders, Sen. Bill Nelson, D-Fla., chair, and Sen. Susan Collins, D-Me., ranking member. ADA’s recommendations:

• Ensure a transparent process where every provider is notified in advance and not when an audit is already underway.

• provide education and compliance training for providers specific to each state program’s regulations.

• provide opportunity for practitioners to have charts and specific cases reviewed by a licensed dentist who has the clinical expertise to conduct a proper evaluation when requested by a dentist or practice that has undergone a RAC audit.

• educate all providers – not just dentists – on the use of extrapolation in the audit process.